Today we’re joined again by Dr. Merima Ruhotina, a minimally-invasive gynecologic surgery fellow at Yale New Haven Hospital in Connecticut. Meri has prepared for us a big series on laparoscopy in gynecology covering many of the fundamentals, particularly to help with the aptly named “Fundamentals of Laparoscopic Surgery” exam that ABOG began to require in 2020.
Here are her notes for Part II!
Today we’re joined by Dr. Merima Ruhotina, a minimally-invasive gynecologic surgery fellow at Yale New Haven Hospital in Connecticut. Meri has prepared for us a big series on laparoscopy in gynecology covering many of the fundamentals, particularly to help with the aptly named “Fundamentals of Laparoscopic Surgery” exam that ABOG began to require in 2020.
Meri is an excellent note taker and we’ll share her episode notes with each episode!
(C) Dr. Merima Ruhotina
(C) Dr. Merima Ruhotina
(C) Dr. Merima Ruhotina
Today we’re thrilled to welcome to the show two folks in the #FOAMed #FOAMob space we admire greatly: Dr. Tamandra Morgan, a current PGY-2 in OB/GYN at UCSF; and Dr. Rachel Berell, who did her intern year in OB/GYN at UC-Irvine and is continuing her training in family medicine, with a focus on obstetrics and public health, at Boston Medical Center.
Together, they run the Instagram page @TheBlackObGynProject, which at the time of our recording has 16,700+ followers. They have created this as a space dedicated to educating and promoting anti-racism, equity, and inclusion within OB/GYN, women’s health, and reproductive health care.
We had a lovely interview with them about their work and their experiences.
The Black OB/GYN Project: Learning, Celebrating, Advocating, Healing.
On their Instagram, they have remarkably well-referenced posts about various instances of racism in the history of medicine, as well as how racism and other biases continue to be a factor today.
The Black OB/Gyn Project, 9/17/20
The Black OB/Gyn Project, 9/17/20
On the show, we mention in particular their September 17, 2020 post on the history of racism in obstetrics and gynecology as an excellent primer to the troubled past of our specialty and its link to today. Other posts include more history of the legacy of James Marion Sims and the impact of racism on postpartum care and hypertension, in particular.
The Black OB/GYN Project, 12/31/20
The Black OB/GYN Project also celebrates Black lives, past and present, and provides a mentoring and celebratory space for folks in the BIPOC community.
And if that weren’t enough, they have provided exhaustive resources on allyship and antiracism, including choices for books and movies. Be sure to check out their posts from 6/4/20, 8/2/20, 9/11/20, and 10/26/20 for their recommendations to date.
The Black OB/GYN Project, 8/2/20
Finally, from the podcast, Tamandra and Rachel share some thoughts for a personal plan to grow as an antiracist:
LEARN: read, watch, listen, and immerse yourself in the history and the present of injustice towards Black / non-white lives and bodies.
PRACTICE: anti-racism daily. It’s not an overnight thing! Be aware of your language, your preconceived notions, and even the patterns of thought you were trained to use becoming a doctor in order to recognize when race plays an inappropriate role in your own work.
BE CRITICAL: look at the scientific literature as you grow as an anti-racist, and ask when race is used as a variable why it was used, how it was obtained, and what significance (if any) racism may have in the true, interpretable results.
After our podcast, a phenomenal blog post/paper in Health Affairs was published, demonstrating a complete lack of focus on racism in the major journals over the last 30 years, while there was plenty to say on “racial differences.”
ADVOCATE: find opportunities locally, regionally, and nationally to bring the best care for your patients of color, and the best treatment for your colleagues of color. Attention has been brought towards the VBAC calculator and the impact of race, for instance. There are many other opportunities where work needs to be done, including in genetic screening and testing, gynecologic surgery, abortion care, and infertility.
Check out: https://www.ajog.org/article/S0002-9378(18)30583-0/fulltext
Remember the evidence-based C-section? Turns out, there is also good evidence for gyn surgery practices!
Preoperative - Includes things that are part of the ERAS protocol
Patient Education
Two randomized control trials
There was some potential association between preoperative patient education and improved outcomes (low level evidence) —> perhaps some decrease in length of stay and pain.
Bowel Prep
Minimally invasive gyn surgery:
Strong evidence that oral mechanical bowel prep should not be used.
In those with high risk of colorectal resection:
Based on colorectal surgery evidence, oral mechanical bowel prep alone is not effective
Use of one of the following regimens can be considered: (moderate level evidence)
Oral bowel prep AND oral antibiotic
Oral antibiotic alone
Surgical site infection bundles - high level of evidence
High level of evidence - use of surgical site infection bundles should be considered!
Listen back to our episode on “Infection Prevention and Gynecologic Surgery”: https://creogsovercoffee.com/notes/2019/10/13/infection-prevention-and-gynecologic-surgery
Sometimes, it’s not always just a single thing, but the whole bundle!
Glucose management
Goal of <180 mg/dL (high level of evidence)
Diet
Reduce fasting - may ingest solids until 6 hours prior to anesthesia induction and clear liquids until 2 hours prior to induction
High level of evidence
Carbohydrate loading - routine carbohydrate loading is recommended (moderate level of evidence)
May ingest 2-3 hours up to induction of anesthesia - can include things like apple juice, ensure clear, etc.
Pre-anesthesia medication
Pain:
Combination of acetaminophen, COX-2 inhibitor (celecoxib, for example), and/or gabapentin - level of evidence is high!
Nausea:
Scopolamine, midazolam, or gabapentin (high level of evidence)
VTE prophylaxis - moderate evidence
Overall low rates of VTE in general, but preoperative intermittent pneumatic compression alone for patients undergoing MIS or laparotomy for benign disease
Weak evidence from observational studies supports adding preoperative pharmacologic prophylaxis for patients undergoing laparotomy for gynecologic malignancies
Intra-operative
Drains
Routine NG tube - associated with patient discomfort and no known benefit (high level of evidence) - from the ERAS Society
Routine peritoneal drains - not recommended routinely in gyn or onc surgery including cases with lymphadenectomy or bowel surgery
2017 Cochrane Database showed drainage was not associated with reduced rates of lymphocyst formation. However, use of surgical drains increased rates of symptomatic lymphocyst formation when the pelvic peritoneum was left open
Overall, moderate evidence
Antibiotic prophylaxis
Given within 1 hour prior to incision per CDC and ACOG; redose prophylactic antibiotics for long procedures (ie. Ancef 3-4 hours after incision)
Level of evidence is high
Skin prep
Ideally use 2% chlorhexidine and 70% isopropyl alcohol solution (high level of evidence)
Blood transfusion (for hemoglobin 6-10) and fluids to maintain intraoperative euvolemia
Maintain normothermia
Pain management - liposomal bupivicaine for laparotomy cases (moderate)
Postoperative
Early mobilization - moderate level of evidence
Has been shown to be beneficial and to avoid prolonged bedrest; basically meaning out off bed and mobilizing within 24 hours of surgery
Reduces PEs and VTEs, also may protect against muscle atrophy and deconditioning
Early alimentation
Postoperative feeding - within 24 hours of surgery (can be as early as 4 hours after surgery with or without bowel resection)
Two systematic reviews and 1 meta-analysis - early feeding is safe, well-tolerated and results in earlier return of bowel function and shorter LOS
Early urinary bladder catheter removal (mod level evidence)
Catheter use for < 24 hours, but appropriate to consider fall risk and necessity of urine output monitoring
Uncomplicated surgeries: consider removal at 6 hours to balance rate of infection vs retention
Complicated: morning after may be more appropriate (ie. urogyn or gyn onc cases)
Prevention of ileus and accelerate return of bowel function
Use of postop laxatives (recommended for gyn surg, low level of evidence)
Docusate sodium (Colace): more about its lack of utility here.
Chewing gum (high level of evidence)
Alvimopan (novel peripheral u-opioid antagonist) - may not be beneficial in benign gyn
However, may decrease ileus in ovarian cancer surgery and can be considered for use in patients undergoing bowel resection
Early IV fluid discontinuation
Discontinue maintenance IV fluids within 12-24 hours following surgery, especially with early PO intake (low level of evidence)
Urine output as low as 20 mL/hour
Can be normal post op stress response
Intervention not required
Postoperative VTE:
Mechanical prophylaxis for duration of hospitalization in all gyn surg patients
Mechanical and/or pharmacologic prophy for gyn onc surgical patients (high level of evidence)
Additionally, for oncology cases with laparotomy, should extend VTE prophylaxis for 4 weeks following surgery
For More Reading: CO 812
Clotting Cascade: An Overview
Listen to the podcast for more, but the most important steps to know are:
Trauma leads to extrinsic pathway and intrinsic pathway (more extrinsic activation)
Both lead into the common pathway, where:
Factor X → Xa
Prothrombin → Thrombin by action of Xa
Fibrionogen → Fibrin by action of Thrombin
Fibrin monomers → polymers → clot by action of factor 13, platelets, and other molecules.
How bad is the bleeding?
Topical agents should be used in places where electrosurgery or sutures are not ideal or safe for the situation -- i.e., near structures like ureters or nerves.
These agents are not ideal for widespread bleeding or use for prophylaxis against bleeding!
Slow, venous bleeding is most adept for these agents -- fast/pumping arterial bleeders, or large areas, are not going to be solved by use of these agents.
Assuming you need one of these, there are three categories of topical agents:
Caustic
Physical
Biologic
Caustic Hemostatic Agents
These agents coagulate proteins leading to tissue necrosis and eschar formation.
Examples -- aluminium chloride, ferric subsulfate 20% (aka Monsel’s solution), silver nitrate, and zinc chloride paste.
These agents are great for topical bleeding, particularly at the cervix or vagina.
They are NOT for intraabdominal use -- they can cause tissue damage and toxicity.
Physical Hemostatic Agents
These products use some sort of substrate to form a matrix at the site of bleeding, providing a scaffold for clot formation via the extrinsic pathway.
Some of the substrates are made of cellulose, gelatin, starch, or collagen.
Because these only provide a matrix to build a clot upon, they are not ideal in patients who have a concern for a coagulation cascade issue -- you need an intact cascade for these to work!
Options in this category:
Gelatin-based (Gelfoam, Gelfim, Surgifoam) -
Available as powder or sponge
Absorbs over 4-6 weeks
Porcine-derived
Absorbs surrounding blood and fluid to increase its size and weight -- great to “apply some pressure” too! But be careful near areas that have fragile structures that shouldn’t be compressed, like near nerves.
Cellulose-based (Surgicel)
Available as powder or knit mesh -- great for using in laparoscopy since you can trim the mesh to size!
Absorbs over 1-2 weeks
Plant-derived
Acidic pH purportedly provides antibacterial properties, and enhances natural thrombosis.
However, this acidic pH will inactivate topical thrombin products, so don’t use these in combination.
Polysaccharide hemospheres (Arista)
Powder
Plant derived
Absorbs within 48 hours -- may be less likely to cause foreign body reaction or form a nidus for infection compared to other physical agents
Absorbs water, allowing platelets and other proteins to accelerate clot formation
Also, this is the only topical agent approved for arterial bleeding!
Microfibrillar collagen (Avitene)
Powder or foam
Bovine-derived
Absorbed in 8-12 weeks
Facilitates platelet aggregation and thrombus formation
Biologic Hemostatic Agents
These bypass the extrinsic/intrinsic pathways to get right to the point of the common pathway, providing a “bolus” of material to promote clotting.
In patients with an impaired coagulation cascade, depending on the step, these may have a more favorable profile than physical agents.
Options in this category:
Topical thrombin (Thrombin-JMI, Recothrom, Evithrom)
Many of these agents are bovine-derived.
Evithrom is derived from pooled human plasma, and thus is considered a blood product.
Recothrom is recombinant, and interestingly should not be used if patients have allergies to snakes or hamsters!
These agents provide thrombin directly, which in turn can go straight to fibrinogen→fibrin activation and clot formation.
If fibrinogen is severely deficient, then these will not work well!
Often topical thrombin is turned into a combination agent with physical hemostatic agents to create a topical gel.
The most well known of this is likely Floseal, which is a combination of bovine-derived gelatin and human-derived thrombin (also a blood product!). Compared to other products and given its combination action, it is more expensive overall.
Fibrin sealants (Tisseel, Evicel)
These are another combination solution that combines human-derived thrombin solution with human fibrinogen solution and can be applied to a bleeding site, forming a clot on the spot!
These are great in that they can be used in patients with coagulopathy, as you are supplying the fibrinogen!
These have to be kept at special temperatures, and often take at least 10-20 minutes to thaw and prepare -- and not surprisingly, these are also quite expensive.
Topical tranexemic acid (TXA)
TXA can be mixed with sterile water and applied directly to bleeding surfaces, and the systemic absorption when performed this way is quite low (<10% of IV form).
This may help abate concerns regarding use of IV TXA in patients who may be prone to thrombosis, but this question needs further study.
Risks and Contraindications to Use
Fortunately, many of these items are well tolerated. But they shouldn’t be used carelessly, for a variety of reasons beyond expense. As we’ve gone through their nature, we should make mention generally of some risks/complications of their use:
The physical agents may be associated with infection.
For physical or combination agents, these are foreign bodies, with varying absorption times. While it’s hard to tease out whether a complex surgery or the agent’s presence led to an infection, it’s worth noting that all of these products have the potential to be a nidus for infection at their site of use.
Confusing things further, these agents often may appear like an abscess or collection on postoperative imaging -- so don’t forget to dictate if and where you used them!
Many of these products are bovine or porcine derived.
Notably, religious leaders from around the world do support use of these animal-derived products if no alternatives are available, or in an emergent situation.
However, being aware of culturally appropriate care is important, and patients who are concerned about this in preoperative counseling should be heard and offered alternatives.
Animal products also have risk of significant allergic reactions!
For instance, there have been reports of severe antibody mediated reactions resulting in catastrophic bleeding on re-exposure to bovine-derived thrombin products. This resulted in a US FDA black box warning for these products.
If used during surgery, patients should be counseled about the use and the potential risks of reexposure with future surgery.
Human-derived samples can be considered blood products, so it’s worth discussing their use in advance with patients who object to use of blood products in surgery.
Human samples also have a theoretical risk of viral contamination and transmission of infections such as HIV or hepatitis. These risks are thought to be very small, however; with the risk of this estimated to be 1 in 10^15 for both thrombin and fibrinogen, and higher for parvovirus (as high as 1 in 500k).
Immunologic events can also rarely occur with use of human products and development of antibodies against human-derived biologic agents; however, this occurs at a much lower incidence compared to bovine-derived thrombin.
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The views expressed herein represent those of the podcast authors personally, not of their institutions.
The podcast should not be reviewed or construed as medical advice.
